Forced migration, trauma, and the risk of mental health disorders among women in the perinatal period
Authors: Susan Rees, Jane Fisher
Journal: The Lancet Public Health (2023)

The systematic review and meta-analysis published in The Lancet Public Health, by Kerrie Stevenson and colleagues,1Stevenson K Fellmeth G Edwards S et al.The global burden of perinatal common mental health disorders and substance use among migrant women: a systematic review and meta-analysis.Lancet Public Health. 2023; 8: e203-e216Google Scholar provides an updated global prevalence estimate of perinatal depressive disorders among women who are migrants, and the first global estimates for anxiety and post-traumatic stress disorder (PTSD) among women who are migrants in the perinatal period. This quality systematic review and meta-analysis offers the migrant and refugee mental health field a comprehensive assessment of current knowledge to inform new studies, policies, and interventions, and to identify dissonance and gaps in knowledge. The review's inclusion of studies examining all common mental health disorders confirmed a predominant focus on depression.2Rees SJ Fisher JR Steel Z et al.Prevalence and risk factors of major depressive disorder among women at public antenatal clinics from refugee, conflict-affected, and Australian-born backgrounds.JAMA Netw Open. 2019; 2e193442Crossref Scopus (14) Google Scholar, 3Anderson FM Hatch SL Comacchio C Howard LM Prevalence and risk of mental disorders in the perinatal period among migrant women: a systematic review and meta-analysis.Arch Women Ment Health. 2017; 20: 449-462Crossref PubMed Scopus (85) Google Scholar, 4Fisher J Cabral de Mello M Patel V et al.Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: a systematic review.Bull World Health Organ. 2012; 90: 139G-149GCrossref PubMed Scopus (1025) Google Scholar, 5Gelaye B Rondon MB Araya R Williams MA Epidemiology of maternal depression, risk factors, and child outcomes in low-income and middle-income countries.Lancet Psychiatry. 2016; 3: 973-982Summary Full Text Full Text PDF PubMed Scopus (587) Google Scholar The review also exposed a prevailing trend to aggregate mental health data for forced and economic migrants despite evidence of a distinctively elevated risk for depression and PTSD in the forced migrant cohorts. Unsurprisingly, there were insufficient data to differentiate anxiety disorder prevalence experienced by women who are forced migrants compared with those who are economic migrants. The review substantiates a need for research attention to risk factors. Although there has been extensive research into both the biological and psychosocial factors that contribute to the risk of maternal mental health disorders in the perinatal period, insufficient research efforts have been made to identify the unique or exacerbated risk factors for common mental health disorders associated with any experience of forced migration, including insecure residency status, poor social supports, and the effects of past and ongoing trauma. Key risk factors for perinatal depression from aggregated (ie, both forced and economic migrants) data included being a recently (ie, approximately within the past year) arrived immigrant, having poor social support, and having a poor relationship with one's partner. Poor partner relationship, measured in various ways across studies, could also be a proxy indicator for intimate partner violence, a factor discussed further on.2Rees SJ Fisher JR Steel Z et al.Prevalence and risk factors of major depressive disorder among women at public antenatal clinics from refugee, conflict-affected, and Australian-born backgrounds.JAMA Netw Open. 2019; 2e193442Crossref Scopus (14) Google Scholar Trauma exposure and functional impairment were understudied despite their theoretical relevance. Exposure to traumatic events is a potent risk factor for mental illness and a salient issue for women who are forced migrants given their experiences of conflict or disaster including witnessing the death of family members, rape, and sexual assault.6Steel Z Chey T Silove D Marnane C Bryant RA van Ommeren M Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: a systematic review and meta-analysis.JAMA. 2009; 302: 537-549Crossref PubMed Scopus (1405) Google Scholar, 7Stark L Ager A A systematic review of prevalence studies of gender-based violence in complex emergencies.Trauma Violence Abuse. 2011; 12: 127-134Crossref PubMed Scopus (218) Google Scholar, 8Rees S Silove D Chey T et al.Lifetime prevalence of gender-based violence in women and the relationship with mental disorders and psychosocial function.JAMA. 2011; 306: 513-521Crossref PubMed Scopus (314) Google Scholar Intimate partner violence is a widely experienced human rights violation and trauma that might be more prevalent during pregnancy, and among women from conflict-affected backgrounds.2Rees SJ Fisher JR Steel Z et al.Prevalence and risk factors of major depressive disorder among women at public antenatal clinics from refugee, conflict-affected, and Australian-born backgrounds.JAMA Netw Open. 2019; 2e193442Crossref Scopus (14) Google Scholar, 4Fisher J Cabral de Mello M Patel V et al.Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: a systematic review.Bull World Health Organ. 2012; 90: 139G-149GCrossref PubMed Scopus (1025) Google Scholar, 7Stark L Ager A A systematic review of prevalence studies of gender-based violence in complex emergencies.Trauma Violence Abuse. 2011; 12: 127-134Crossref PubMed Scopus (218) Google Scholar Despite functional impairment being a robust indicator of mental health disorders, and for how well migrants manage challenges and engage with opportunities during settlement, it is also generally neglected in studies, especially those conducted in the perinatal period.9Tay AK Rees S Miah MAA et al.Functional impairment as a proxy measure indicating high rates of trauma exposure, post-migration living difficulties, common mental disorders, and poor health amongst Rohingya refugees in Malaysia.Transl Psychiatry. 2019; 9: 213Crossref PubMed Scopus (26) Google Scholar, 10Rees S Mohsin M Moussa B et al.Cohort profile: intimate partner violence and mental health among women from refugee background and a comparison group of Australian-born–the WATCH cohort study.BMJ Open. 2022; 12e051887Crossref Scopus (2) Google Scholar Notwithstanding the dissimilarity in mental health status between people who arrived as economic or forced refugees, the authors recognised the challenges in defining these often-interrelated migration categories. The absence of disaggregated data on PTSD and trauma among economic migrants possibly indicates the use of poorly selected indices. Climate change and COVID-19, for example, are of major contemporary interest to the mental health field, and they are independently interrelated with economic distress, intimate partner violence, fleeing for safety, and psychological distress. The review's contribution to research, policy, and practice would have benefited from a method that did not construct forced migrants as a heterogeneous population. In this paper, forced migrants were defined as refugees or asylum seekers, however not all asylum seekers will ultimately be recognised as refugees. Asylum seekers with insecure residency experience more harmful fear and anxiety associated with forced repatriation to the country of origin than those with refugee status. The results from this review fortify calls for perinatal mental health research to give specific focus to women arriving as migrants from low-income, conflict-affected backgrounds.2Rees SJ Fisher JR Steel Z et al.Prevalence and risk factors of major depressive disorder among women at public antenatal clinics from refugee, conflict-affected, and Australian-born backgrounds.JAMA Netw Open. 2019; 2e193442Crossref Scopus (14) Google Scholar The paper confirms that research might be failing to accurately characterise this population who are at high-risk of developing mental health disorders. There is also insufficient emphasis on distinctive risk factors, and a need for more longitudinal studies and interventions.2Rees SJ Fisher JR Steel Z et al.Prevalence and risk factors of major depressive disorder among women at public antenatal clinics from refugee, conflict-affected, and Australian-born backgrounds.JAMA Netw Open. 2019; 2e193442Crossref Scopus (14) Google Scholar, 3Anderson FM Hatch SL Comacchio C Howard LM Prevalence and risk of mental disorders in the perinatal period among migrant women: a systematic review and meta-analysis.Arch Women Ment Health. 2017; 20: 449-462Crossref PubMed Scopus (85) Google Scholar We further recommend that future studies examine theoretically germane disorders, particularly in women who are forced migrants. Women migrating from conflict-affected backgrounds experience much higher rates of PTSD, as well as hitherto overlooked disorders including Adult Separation Anxiety Disorder and grief disorder, both of which can be exacerbated in pregnancy, when compared with women born in the host country.10Rees S Mohsin M Moussa B et al.Cohort profile: intimate partner violence and mental health among women from refugee background and a comparison group of Australian-born–the WATCH cohort study.BMJ Open. 2022; 12e051887Crossref Scopus (2) Google Scholar, 11Eapen V Johnston D Apler A Rees S Silove DM Adult separation anxiety during pregnancy and its relationship to depression and anxiety.J Perinat Med. 2013; 41: 159-163Crossref PubMed Scopus (5) Google Scholar The review by Stevenson and colleagues1Stevenson K Fellmeth G Edwards S et al.The global burden of perinatal common mental health disorders and substance use among migrant women: a systematic review and meta-analysis.Lancet Public Health. 2023; 8: e203-e216Google Scholar found that women who arrived as migrants in high and low-middle-income countries are at considerable risk for mental health disorders during the perinatal period. It shows that specific issues effect the mental wellbeing of women who are forced migrants, and in addition to prevalence, more research is required to examine risk factors. A more comprehensive understanding of mental health disorders as well as historical and contemporary risk factors will indeed assist with targeting women at highest risk for mental disorders, and identifying where to address systemic barriers and inequities. We declare no competing interests. The global burden of perinatal common mental health disorders and substance use among migrant women: a systematic review and meta-analysisOne in four women who are migrants and who are pregnant or post partum experience perinatal depression, one in five perinatal anxiety, and one in 11 perinatal PTSD. The burden of perinatal mental illness appears higher among women who are forced migrants compared with women who are economic migrants. To our knowledge, we have provided the first pooled estimate of perinatal depression and PTSD among women who are forced migrants. Interpreting the prevalence estimate should be observed with caution due to the very wide range found within the included studies. Full-Text PDF Open Access